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Long-term strategies to control COVID-19 in low and middle-income countries: an options overview of community-based, non-pharmacological interventions

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In low and middle-income countries (LMICs), strict social distancing measures (e.g., nationwide lockdown) in response to the COVID-19 pandemic are unsustainable in the long-term due to knock-on socioeconomic and psychological effects. However, an optimal epidemiology-focused strategy for 'safe-reopening' (i.e., balancing between the economic and health consequences) remain unclear, particularly given the suboptimal disease surveillance and diagnostic infrastructure in these settings. As the lockdown is now being relaxed in many LMICs, in this paper, we have (1) conducted an epidemiology-based "options appraisal" of various available non-pharmacological intervention options that can be employed to safely lift the lockdowns (namely, sustained mitigation, zonal lockdown and rolling lockdown strategies), and (2) propose suitable application , prerequisites , and inherent limitations for each measure. Among these, a sustained mitigation-only approach (adopted in many high-income countries) may not be feasible in most LMIC settings given the absence of nationwide population surveillance , generalised testing, contact tracing and critical care infrastructure needed to tackle the likely resurgence of infections. By contrast, zonal or local lockdowns may be suitable for some countries where systematic identification of new outbreak clusters in real-time would be feasible. This requires a generalised testing and surveillance structure, and a well-thought out (and executed) zone management plan. Finally, an intermittent, rolling lockdown strategy has recently been suggested by the World Health Organization as a potential strategy to get the epidemic under control in some LMI settings, where gener-alised mitigation and zonal containment is unfeasible. This strategy, however, needs to be carefully considered for economic costs and necessary supply chain reforms. In conclusion, while we propose three community-based, non-pharmacological options for LMICs, a suitable measure should be context-specific and based on: (1) epidemiological considerations, (2) social and economic costs, (3) existing health systems capabilities and (4) future-proof plans to implement and sustain the strategy.
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Vol.:(0123456789)
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European Journal of Epidemiology (2020) 35:743–748
https://doi.org/10.1007/s10654-020-00660-1
COVID-19
Long‑term strategies tocontrol COVID‑19 inlow
andmiddle‑income countries: anoptions overviewof
community‑based,non‑pharmacological interventions
RajivChowdhury1 · ShammiLuhar1· NusratKhan1· SohelRezaChoudhury2· ImranMatin3· OscarH.Franco4
Received: 14 June 2020 / Accepted: 1 July 2020 / Published online: 13 July 2020
© The Author(s) 2020
Abstract
In low and middle-income countries (LMICs), strict social distancing measures (e.g., nationwide lockdown) in response
to the COVID-19 pandemic are unsustainable in the long-term due to knock-on socioeconomic and psychological effects.
However, an optimal epidemiology-focused strategy for ‘safe-reopening’ (i.e., balancing between the economic and health
consequences) remain unclear, particularly given the suboptimal disease surveillance and diagnostic infrastructure in these
settings. As the lockdown is now being relaxed in many LMICs, in this paper, we have (1) conducted an epidemiology-based
“options appraisal” of various available non-pharmacological intervention options that can be employed to safely lift the
lockdowns (namely, sustained mitigation, zonal lockdown and rolling lockdown strategies), and (2) propose suitable applica-
tion, pre-requisites, and inherent limitations for each measure. Among these, a sustained mitigation-only approach (adopted in
many high-income countries) may not be feasible in most LMIC settings given the absence of nationwide population surveil-
lance, generalised testing, contact tracing and critical care infrastructure needed to tackle the likely resurgence of infections.
By contrast, zonal or locallockdowns may be suitable for some countries where systematic identification of new outbreak
clusters in real-time would be feasible. This requires a generalised testing and surveillance structure, and a well-thought out
(and executed) zone management plan. Finally, an intermittent, rolling lockdown strategy has recently been suggested by
the World Health Organization as a potential strategy to get the epidemic under control in some LMI settings, where gener-
alised mitigation and zonal containment is unfeasible. This strategy, however, needs to be carefully considered for economic
costs and necessary supply chain reforms. In conclusion, while we propose threecommunity-based, non-pharmacological
optionsfor LMICs, a suitable measure should be context-specific and based on: (1)epidemiological considerations, (2)social
and economic costs, (3)existing health systems capabilities and (4)future-proof plans to implement and sustain the strategy.
Keywords COVID-19· Low and middle-income countries· Non-pharmacological interventions· Exit plan· Zonal
lockdown· Local lockdown· Rolling lockdown· Mitigation
Introduction
The coronavirus disease-2019 (COVID-19) pandemic has
claimed more than 500,000 lives worldwide [1] and has been
responsible for significant economic disruptions globally [2].
Similar to the high-income nations, low and middle-income
countries (LMICs) also responded to COVID-19 by imple-
menting various population-level measures, including strict
nationwide lockdowns and physical distancing [3]. World-
wide, with no effective treatments for COVID-19 and a vac-
cine at least a year away, these measures have been gener-
ally effective in preventing health systems from becoming
overloaded, especially in the LMICs where: (1) the risk of
disease transmission is high (populations are often large and
Rajiv Chowdhury, Shammi Luhar, and Nusrat Khan contributed
equally.
* Rajiv Chowdhury
rc436@medschl.cam.ac.uk
1 Department ofPublic Health andPrimary Care, School
ofClinical Medicine, University ofCambridge, Cambridge,
UnitedKingdom
2 Department ofEpidemiology, National Heart Foundation
Hospital andResearch Institute, Dhaka, Bangladesh
3 Brac Institute forGovernance andDevelopment, Brac
University, Dhaka, Bangladesh
4 Institute ofSocial andPreventive Medicine, University
ofBern, Bern, Switzerland
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
744 R.Chowdhury et al.
1 3
dense, with a high degree of interaction and physical con-
tact), (2) awareness of how to prevent disease is often poor
(eg, clean water and hygiene practices), (3) public health
systems are often under-resourced (eg, safety equipment and
intensive care units/ICU), and (4) access to healthcare is
limited and reliant on largely out-of-pocket payment.
These strict social distancing interventions, however,
come with a price: they are unsustainable in the long term
given their social, economic and psychological impacts.
For example, a recently completed survey in Bangladesh
showed that after its initial days of lockdown, a staggering
72% of urban and 54% of rural households had lost their
main source of earnings [4]. Therefore, many LMICs are
currently lifting the lockdowns, irrespective of the status of
infection and the level of contagion. It remains, however,
unclear what would be an optimal strategy for ‘safe re-open-
ing’ (given the likelihood of disease resurgence), especially
across low-income settings, where diagnostic capacities and
surveillance infrastructure is poor [5].
In this regard, we have considered three community-
based non-pharmacological strategies for LMICs (which aim
to strike a balance between health protection and prevent-
ing economic collapse) and propose appropriate application,
ideal pre-requisites, and inherent limitations for each. They
include: (1) sustained mitigation, (2) zonal lockdown, (3)
rolling lockdown (dynamic measures). These strategies (as
summarized in Fig.1) should not be considered as mutu-
ally exclusive, and could be further adapted and combined
depending on local disease epidemiology and socioeco-
nomic circumstances.
Sustained mitigation
Following theinitial national lockdowns, staying on a ‘mit-
igation-only’ phase (a strategy adopted by developed coun-
tries such as France, Switzerland and Italy) has involved
measures such as physical distancing, wearing masks, test-
trace-isolation of suspected cases, shielding of the vulner-
able and banning mass gatherings [6]. The successful imple-
mentation of this no-lockdown mitigation-onlyapproach,
however, is contingent on a number of key factors.
First, the implementation of the earlier strict lockdown
has resulted in a significant reduction of contact rates, new
infections, and case fatality in the country [7, 8]. In this
regard, somewhat worryingly, many LMICs, where lock-
down has recently been lifted, appear to have an upward
trend of cases and deaths [9]. Second, there isavailability of
nationwide surveillance, mass testingoperations and rapid
case isolation to tackle any resurgence and tofacilitate con-
tainment [10, 11]. Third, for contact-tracing, enough trained
contact tracers (or scalable digital platforms)are available,
with a relatively sparse target population (minimising the
possibility of super-spreading events). In this regard, the
effectiveness of contact-tracing might be importantly mini-
mised in large, dense countries such as Bangladesh (~ 1300
people/sqkm), compared to sparsely populated countries
like Spain (~ 90 people/sqkm) [12]. Contact-tracing is also
less effective at the height of community spread when the
rates are on the rise. Fourth, individual and population-level
adherence to mitigation measures (eg, physical distanc-
ing, hygiene, home quarantine)will be ensured. For many
LMICs, however,this remains a challenge given large-scale
social stigma and suboptimal risk communication strategies
[13]. Finally, healthcare services must be able to adequately
cope with the resurgence in new cases, including availability
of specialised care, hospitals and ICU beds. In many LMICs,
there is however a chronic shortage of (1) critical care infra-
structure (only 48,000 ventilators are available in India to
serve its 1.3 billion people [14]), (2) personal protective
equipment (PPE), (3) training of health workforce, and
(4) good working conditions—all of which reduce system
efficiency and enhance likelihood of transmission among
healthcare workers.
Despite being farless restrictive than afull lockdown,
a mitigation-only strategy is alsonot immune to financial
hardship as it can lead to somesocioeconomic disrup-
tion(e.g., reduced production due to workplace social dis-
tancing) – somewhat compromising its sustainability over
a prolonged period. For example, Sweden adopted some of
the most liberal mitigation measuresin the world such as
keeping restaurants, bars, and gyms open throughout the
previous few months, whilst encouraging physical distancing
rules. However, the countryis stillexpected to suffer ~ 10%
contraction in its economy in 2020 according to the Swedish
Central Bank [15].
Zonal lockdown
The idea of fencing between infected and healthy communi-
ties, termed cordon sanitaire, has been deployed during a
variety of outbreaks for centuries. In line with this principle,
as an exit strategy, many countries have transitioned to a sys-
tem of “zonal (or local)lockdown” [16]. This system entails
identification of specific “hotspots” where a sudden outbreak
cluster, with a high number of cases, have been identified in
real time. Such clustered social distancing works by dividing
the population into “zones” according to the geospatial dis-
tribution of disease cluster contained within, so that interac-
tions within a zone are significantly greater than interactions
between zones [17]. Transmission hotspots, or “red zones”
are subject to strict lockdown measures than “green zones”,
where very few or no new cases have been identified for
several days. Such strategies were adopted in France [17],
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745
Long-term strategies tocontrol COVID-19 inlow andmiddle-income countries: anoptions overview…
1 3
Fig. 1 A visual summary of the three proposed community-based non-pharamacological option for developing countries
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
746 R.Chowdhury et al.
1 3
with green zones defined by areas where the virus transmis-
sion is relatively low and there is not as burdensome pressure
placed on the healthcare system.
The “zonal lockdown” approach has several important
requirements. First, this categorisation of hotspots is typi-
cally a dynamic process, which requires an ability to reli-
ably identify, in real time, areas that meet or fall short of
the pre-specified lockdown criteria. This requires continu-
ous data-driven feedbacks on: (1) regional daily confirmed
cases (either by date of reporting or onset of symptoms),
and (2) other time-series information needed to calculate
the changes in region-specific effective reproduction number
(R, the average number of secondary infections per infected
individual), including daily numbers of hospitalized cases,
daily numbers of deaths in different age groups, and trans-
mission dynamics (eg, average time from infection to death)
[17]. While such strategy has been successfully established
in developed settings (such as France, where testing is wide-
spread with 0.52 daily tests being done per 1000 population),
this remains challenging in many LMICs due to (1) absence
of large-scale population surveillance system based on ran-
domly-selected individuals (e.g., in Bangladesh, the testing
approach has focused on purposive, self-referred samples,
with significant selection bias), and (2) poor testing labora-
tory facilities and reporting capacities (e.g., in Pakistan, only
0.09 daily tests are being conducted per 1000 individuals)
[18]. In this regard, India has adapted a scalable mass "Pool
testing" approach [19]. This cost-effective strategy involves
collecting multiple samples in a tube and testing them with
a single RT-PCR assay run. If the test is negative, all the
people tested are negative. If it is positive, every person has
to be tested individually for the virus. This approach reduces
the time needed to test large swathes of the population [20].
Second, the classification of the zones should also be
multifactorial. This should not only take into considera-
tion the incidence rate, but also the other epidemiological
(e.g., doubling rate of new cases; number of deaths) and
administrative aspects (e.g., available hospital and ICU
beds; testing and surveillance structure; residential versus
industrial zone). Third, managing the zones efficiently to
reduce transmission both within and outside of the zones
is a major undertaking. Recent reports from India shows
that infection size in many containment areas is 100-fold
to 200-fold higher than the cases reported at those sites—
indicating that containment efforts within zones may not
have fully paid off [21]. Therefore, detailed apriori standard
operating procedures should be devised to include aspects
on (1) within-zone public health measures (eg, risk commu-
nication, house-to-house surveillance, test booths, contact-
tracing, case referral systems, ambulance and medical facili-
ties), (2) within-zone measures of emergency services (eg,
food supply, law enforcement, isolation centres, and burial
facilities), and (3) outside-zone measures such as creation
of “buffer” zones (e.g., in India [19]) that surround the main
containment zone to minimise out-of-zone transmissions.
Such detailed protocols are crucial for efficiency. In Iran, for
example, suboptimal zone management has increased risk of
a second wave [22]. Finally, similar to sustained mitigation
strategy, the zonal lockdown will be most effective when
the overall rate of infection is in decline, accompanied by
exhaustive vigilance.
While zonal lockdown, if implemented properly, can help
contain the spread of the virus, efficacy of this approach
can be reduced by other concurrent transmission networks,
such as those linked to economic and social interdependency
between zones [17]. Additionally, the impacts on the econ-
omy, particularly inside the zones, can be considerably more
severe than under mitigation where the economy essentially
opens with restrictions, exacerbating economic hardship in
countries with already weak economic performance and
social security nets. Therefore, these aspects merit careful
consideration during the planning phase of this strategy.
Rolling lockdown
Intermittent or “rolling” lockdown measures take place when
strict social distancing measures are applied and lifted peri-
odically. This strategy has been described as a potentially
effective measure to minimise uncertainty in both effective
R values, and in the severity of the virus (i.e. the propor-
tion of cases requiring ICU admission) [23]. This approach
may be particularly suitable for the LMICs with large and
dense populations, high patterns of contact, poor economic/
health systems resilience, and weak testing/contact tracing
capacities. Furthermore, this approach addresses both key
elements of society that needs safe-keeping: life and liveli-
hood, and aims to provide a balance between avoiding public
health systems being overloaded and grinding economies
completely to a halt [24]. A recent paper mathematically
modelled the effects of either a strict 50-day suppression
or a 50-day mitigation, followed by 30days of relaxation
(during which businesses are allowed to reopen, with basic
hygiene measure kept in place), in 16 economically diverse
countries. In these models, a strict 50-day lockdown, that
reduces the effective R value to 0.5, prevented ICU beds
overload and led to considerably fewer deaths (130,000
during 18months in the 16 countries they modelled) com-
pared to a more relaxed 50-day mitigation/30-day relaxation
cycle (~ 3.5 million predicted deaths globally) and under no-
intervention (counter-factual) scenario (8 million predicted
deaths) [25]. To further contextualize the value of such con-
cept, a subsequent paper estimated that (1) a single, one-off
lockdown will be insufficient to bring the pandemic under
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747
Long-term strategies tocontrol COVID-19 inlow andmiddle-income countries: anoptions overview…
1 3
control, and (2) secondary peaks would be larger than the
first, without continued restrictions [26].
However, as with the other strategies, rolling lockdown
approach is also contingent on several factors. First, before
implementing a rolling lockdown, every developing country
should carefully consider the economic and social costs to
implement these measures. Second, impacts on incidence and
case-fatality will rely on local levels of adequate adherence
to social distancing measures. Third, this approach would
also bring a new set of logistical challenges. Therefore, coun-
tries will need to formulate bespoke plans for reorganising
business supply chains, so that they align with the economy
opening and closing. While such readjustments to comple-
ment a schedule of lockdown is not ideal, unprecedented
challenges often require unusual and adaptive solutions,
especially if other alternative exit strategies are not feasi-
ble. Finally, by establishing a detailed surveillance system
while the lockdown takes place, countries should adapt the
duration of the lockdown and relaxation periods according
to the local growth rate and pattern of the epidemic. A recent
example of this has been in Pakistan, where the World Health
Organization has recommended a 14-day-on/14-day-off roll-
ing lockdown to control the epidemic [27]. Similarly, rolling
lockdowns do not have to be generalised, these can also be
adapted as regional or zonal rolling lockdowns within a coun-
try, i.e., to apply specifically in areas with high and sustained
new-onset COVID-19 cases per population.For example,
zonal rolling lockdowns have been proposed in theGauteng
province of South Africa—one of the worst affected regions
in the country—to control the rapid increase in infection rates
[28].
Conclusion
While many LMI countries are currently lifting the lock-
downs due to economic reasons, it is crucial for the policy
makers to recognise that preserving health is equally impor-
tant for reviving the economy. This is of important relevance
to the LMICs where large proportions of working-age popu-
lation are vulnerable to adverse COVID-19 outcomes, owing
to high prevalence of comorbid conditions (such as diabetes,
obesity and hypertension) [29]. Furthermore, if a country
has constant high incidence of adeadly disease, it may
become rather challenging for the local economy to thrive
in such environment [30].Therefore, equal priorities must
be put on protecting lives as well as livelihood when adapt-
ing an exit plan. In this regard, we have proposedseveral
non-pharmacological strategies that may enable the LMICs
to safely open the economy, while allowing for preserva-
tion of health. However, it is crucial that theselection ofa
suitable, “context-specific” strategyis based on some key
considerations: (1) local epidemic growth rate, (2) existing
health infrastructure (to survey, test, and treat, at scale), (3)
social and economic costs, and (4) carefully-devised plans
to implement and sustain the measures.
Author contributions RC conceptualised the paper. RC, SL and NK
led the manuscript drafting. OHF, SRC and IM provided scientific and
technical comments to strategic options discussed in this manuscript.
RC, SL and NK did the necessary background literature review.IM
and RC produced the visual abstract. RC leads several COVID-19
projects and published COVID-19 modelling studies related to non-
pharmacological interventions. SL is an epidemiologist involved
with various Cambridge-led COVID-19 projects. NK is a clinician
and doctoral researcher in global public health involved with various
Cambridge-led COVID-19 projects. OHF is the Director of Institute
of Social and Preventive Medicine at the University of Bern, where
he advises various national (Switzerland) and regional (Latin Amer-
ica) COVID-19 technical response committees. SRC is a member of
COVID-19 Technical Response Committee in Bangladesh. IM is the
Executive Director of BRAC Institute of Global Development, leading
an ongoing BRAC-SOAS-Cambridge project to formulate an adaptive
and integrated framework for health responses to COVID-19 in the
developing countries.
Compliance with ethical standards
Conflict of interest None to declare.
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permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.
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... Following the breakout and declaration of the novel coronavirus disease 2019 (COVID- 19), a pandemic in early 2020, national governments the world over instituted measures to contain its spread [1,2]. Besides the creation of awareness about the disease, institution of quarantine rules and restrictions on international travel, and promotion of personal preventive and protective measures, such as the wearing of face masks, hand washing, sanitizing, and physical distancing [3,4], some of the early actions taken by several countries to control the spread of COVID-19 also included enforcement of national lockdowns [1,[5][6][7][8]. It is estimated that over 50 countries across the globe imposed lockdowns for periods ranging from weeks to months, as a measure to control the spread of COVID-19 [9]. ...
... While the degree of lockdown may range from partial/local to total/nationwide [3,10] and the restrictions enforced vary across countries and regions, lockdowns imposed to control the spread of COVID-19 typically involved restrictions on movement, home confinement, shutdown of public transport, closure of schools and businesses, and banning of public gatherings [7,11]. ...
... In as much as they are generally shown to be effective in containing the spread of COVID-19 and other infectious diseases [5,7,11,14], lockdowns are associated with a myriad of negative impacts on national economies and livelihoods of individuals and households [3,5,15]. For instance, a survey of 40,000 people in all the States of India found that loss of jobs was the immediate effect of the COVID-19 lockdown on the livelihoods of individuals [16]. ...
Article
Full-text available
The declaration of the coronavirus disease 2019 (COVID-19) pandemic led to the enforcement of national lockdowns in several countries. While lockdowns are generally effective in containing the spread of infectious diseases, they are associated with negative impacts on livelihoods. Although evidence suggests that urban informal sector populations in low-resource settings bore the brunt of the adverse economic effects of COVID-19 lockdowns, there is little on how they survived. The article provides insights into the survival mechanisms of urban informal sector populations during a COVID-19 lockdown. Data are from narrative interviews with 30 residents of Kampala City and surrounding areas. We found that the COVID-19 lockdown chiefly jeopardized the livelihoods of urban residents through job loss and reduced incomes. Affected individuals and households primarily survived by making improvisations such as adjusting expenditures and reconfiguring their livelihoods. The cardinal elements of the informal sector, such as limited regulation, served as both a facilitator and constraint to survival. Therefore, the informal sector is an important buffer against livelihood shocks in situations of crisis. However, its inherent limitations imply that promoting livelihood resilience among urban residents during lockdowns and similar shocks may necessitate harnessing both formal and informal safety nets.
... Introduction mental preparedness of the people. [2] The pandemic has grown rapidly in 14 weeks' time since the first case of severe pneumonia was reported to WHO by the Chinese authority. [1] Nonpharmacological interventions are available to prevent infection such as the practice of good personal hygiene habits (handwashing, coughing into tissue or elbow, and avoiding touching eyes, nose, and mouth) and social distancing. ...
... [1] Nonpharmacological interventions are available to prevent infection such as the practice of good personal hygiene habits (handwashing, coughing into tissue or elbow, and avoiding touching eyes, nose, and mouth) and social distancing. [2] The Ministry of AYUSH, Government of India recommended measures such as adding turmeric to milk, turmeric in food, and intake of herbal tea during COVID-19. [3] Hence, the present study was undertaken to know the awareness and practices about nonpharmacological interventions of COVID-19. ...
Article
Full-text available
Introduction: COVID‑19 pandemic is a major global public health threat. Coronavirus includes a large group of viruses, which infects both humans and animals. China reported the outbreak on December 31, 2019, to World Health Organization. Center for Disease Control and Prevention, USA, has published nonpharmacological interventions such as social distancing, zonal lockdown, rolling lockdown, wearing masks, and washing hands to combat the spread of COVID‑19. The present study was conducted to assess the perceptions of people about nonpharmacological interventions in the prevention of COVID‑19. Materials and Methods: A facility‑based study was conducted among 220 participants from December 01, 2020, to February 28, 2021, among outpatients in the field practice area of urban primary health care Rukmini Nagar, under the administrative control of J. N. Medical College in Belagavi district, Karnataka. Results: A total of 220 participants were interviewed and analyzed for the study. Out of which, 36 (16.4%) were male and 184 (83.6%) were female. One hundred and seventy (77.2%) of the participants practiced good hand hygiene and personal hygiene. One hundred and forty‑five (65.9%) of the participants always wore a face mask, when they were going outside. One hundred and eighty‑one (82.2%) of the participants started drinking more fluids in the form of water compared with normal days. Conclusion: There was a lack of awareness about face protection and the use of hand sanitizer among the common public. Grassroots level health‑care workers such as Accredited Social Health Activist, Anganwadi workers, and community volunteers should be trained for giving health education about nonpharmacological interventions to the public for COVID‑19 prevention. Keywords: COVID‑19 preventions, nonpharmacological interventions, urban health center
... Quando trazemos para o Brasil, o primeiro caso oficial de COVID-19 foi registrado em 26 de fevereiro de 2020, mesmo que já houvesse rumores sobre casos em território brasileiro desde janeiro; deste momento em diante, a contaminação por COVID-19 cresceu de forma acelerada e agressiva no país. O paciente do primeiro caso confirmado foi contaminado em sua viagem à Itália, o que se tornou uma tendência, quando consideramos que o principal vetor da transmissão internacional da doença para o território nacional foram indivíduos que haviam retornado de suas viagens à Itália para o Brasil, principalmente aos estados de Rio de Janeiro e São Paulo (CÂNDIDO et al., 2020).Impactos da pandemia na estrutura das cadeias produtivasA primeira medida que muito países tomaram, que afetou diretamente como se daria o comércio internacional no período da pandemia, foi o fechamento das fronteiras.Logo em seguida, ocorreu uma disputa generalizada entre países, para garantir os recursos que se tornaram essenciais, como vacinas, ventiladores pulmonares, máscaras e outros equipamentos de proteção(CHOWDHURY et al., 2020).A pandemia de COVID-19 foi responsável pelo esgotamento de diversos produtos, nos mais diversos países, como os mencionados anteriormente. O que se tornou evidente com a crise foi a interdependência das cadeias de produção do mundo inteiro.Um exemplo é a dependência que os Estados Unidos e a Índia têm quanto aos remédios chineses; 97% dos remédios usados nos Estados Unidos são importados da China, enquanto cerca de 40 a 50% dos princípios ativos utilizados pelos remédios indianos são, na verdade, chineses. ...
Article
Full-text available
O presente artigo tem por objetivo principal avaliar o comportamento das relações comerciais sino-brasileiras no pós-pandemia, focando-se nas exportações, analisando ainda as características de cada fase desse relacionamento e a pauta exportadora, considerando os dados brutos em valores de exportação e a classificação das mercadorias entre os anos de 2009 e 2021. Para isso, foi usado o método histórico e comparativo, assim como o cálculo de Market-Share e uma análise de tendência a partir de uma regressão linear simples. Os dados e resultados foram respectivamente tratados e obtidos por meio do Microsoft Excel ®. Concluiu-se que a pandemia teve pouco impacto nas exportações brasileiras para a China, visto que seu Market-Share e valores continuaram crescendo entre 2019 e 2021.
... 2021. o acúmulo científico consolidou as evidências e, a partir do segundo semestre de 2020, já havia um consenso na comunidade científica internacional sobre as medidas não farmacológicas eficazes no contexto da pandemia da covid-19 (Chowdhury et al., 2020). ...
... The COVID-19 pandemic has triggered much research into the role of social distancing in viral spread, especially because before the advance of vaccination, non-pharmaceutical intervention (NPI) measures were the only intervention available (Lewnard and Lo 2020). NPI policies have taken a variety of forms such as extreme lockdowns, school closures, road and transit systems restrictions, and mandatory isolation/quarantine (Kupferschmidt and Cohen 2020), see, e.g., Feng et al. (2020), Vokó and Pitter (2020), Chowdhury et al. (2020), Kissler et al. (2020), Ferguson et al. (2020), Koo et al. (2020), Hellewell et al. (2020), Gatto et al. (2020), Wang et al. (2020), Liu et al. (2020), Li et al. (2020) on the effects of mandated social distancing on SARS-CoV-2 spread. In a recent paper Huang et al. (2021), the authors considered the combination of both mandated and selfregulated types of social distancing, and studied their effect on the outbreak threshold of an (asymptomatic) infectious disease. ...
Article
It is well known in the literature that human behavior can change as a reaction to disease observed in others, and that such behavioral changes can be an important factor in the spread of an epidemic. It has been noted that human behavioral traits in disease avoidance are under selection in the presence of infectious diseases. Here, we explore a complementary trend: the pathogen itself might experience a force of selection to become less “visible,” or less “symptomatic,” in the presence of such human behavioral trends. Using a stochastic SIR agent-based model, we investigated the co-evolution of two viral strains with cross-immunity, where the resident strain is symptomatic while the mutant strain is asymptomatic. We assumed that individuals exercised self-regulated social distancing (SD) behavior if one of their neighbors was infected with a symptomatic strain. We observed that the proportion of asymptomatic carriers increased over time with a stronger effect corresponding to higher levels of self-regulated SD. Adding mandated SD made the effect more significant, while the existence of a time-delay between the onset of infection and the change of behavior reduced the advantage of the asymptomatic strain. These results were consistent under random geometric networks, scale-free networks, and a synthetic network that represented the social behavior of the residents of New Orleans.
... Hence, measures alternative to lockdown for limiting the social contacts are important to limit the transmission and prevent the surge in the cases. [31][32][33] We attempted to define compliance to lockdown in terms of reduction of social contacts, which may be useful to inform the effectiveness of non-pharmacological intervention (NPI) models for infection transmission in the region. Four out of five participants reduced their contact rates to at least 75%, while the majority had reduced their contacts by half during the lockdown period. ...
Article
Objective: This study was undertaken to assess the change in social contact and transmission dynamics among adults in the Puducherry district during the different phases of country‑wide lockdown. Methods: Adults aged 18–69 years in Puducherry were assessed for frequency and duration of contacts in the following time points: prior to lockdown (March 2020), during lockdown, immediate post‑lockdown (April, June 2020), and seven months post‑lockdown (February 2021). Adjusted incidence rate ratios (aIRR) were obtained using a generalized estimating equation. We also assessed the exponential trajectory of the time‑varying reproduction number (Rt) during and after lockdown. Results: Compared to pre‑lockdown phase, frequency of social contacts during 1st week, 4th week of lockdown, and immediate post‑lockdown were reduced by 89% (aIRR = 0.11; 95% CI: 0.09–0.13), 40% (aIRR = 0.60; 95% CI: 0.52–0.69) and 91% (aIRR = 0.09; 95% CI: 0.07–0.10) respectively. However, the decline was not statistically significant at seven months post‑lockdown. Correspondingly, we observed an initial spike in Rt during the lockdown phase followed by a gradual decline during the immediate post‑lockdown phase. However, seven months post‑lockdown, Rt has increased again. Conclusion: The study showed high compliance to the lockdown measures in Puducherry during the lockdown and immediate post‑lockdown periods. However, as the lockdown measures were relaxed, the contact rate returned to the pre‑lockdown state.
... Since the outbreak of COVID-19, in addition to research on the origins [13][14][15], pathology [16,17], characteristics [18][19][20], and pharmacological and non-pharmacological interventions [21][22][23] of COVID-19, a large number of studies have focused on the correlation between physical activity and the disease. Some scholars have discussed the negative impact of the COVID-19 pandemic on physical activity due to the implementation of preventive and control measures such as lockdowns, which made it easier to lead a sedentary life during the pandemic [6,16,[24][25][26], adversely affecting people both psychologically [27] and physiologically [6,28]. ...
Article
Full-text available
This study aims to investigate the effects and influencing mechanisms of regular physical activity (RPA) on the COVID-19 pandemic. Daily data from 279 prefecture-level cities in mainland China were collected from 1 January to 17 March 2020. A two-way fixed-effects model was used to identify the causal relationship between physical activity and COVID-19, while also considering factors such as patterns of human behavior and socioeconomic conditions. The instrumental variable (IV) approach was applied to address potential endogeneity issues for a more accurate causal identification, and the mediating effect model was applied to examine the mechanisms of the influence of physical activity on the epidemic. We found that regular physical activity significantly improves individual immunity, which, in turn, leads to a reduction in the probability of being infected with COVID-19. Furthermore, we investigated the heterogeneity of the influence, finding that the negative impact of physical activity on the pandemic is more pronounced in the absence of adequate medical resources, strong awareness of prevention among residents, and fully implemented public health measures. Our results provide empirical evidence for the mechanisms of influence of physical activity on the pandemic. We would suggest that not only should physical activity be actively practiced during the pandemic, but also long-term regular exercise habits should be consciously cultivated to improve the ability of the individual immune system to better cope with sudden outbreaks of emerging infectious diseases.
Article
The landscape of pediatric vaccination has changed dramatically due to changing attitudes toward immunizations and recent world events. The rise of vaccine hesitancy and refusal related to the concurrent rise of social media and anti-vaccination messages with misinformation campaigns have led to populations of children being unimmunized or under-immunized. These populations have been left vulnerable to the rapid spread of vaccine-preventable infection. Additionally, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the clinical syndrome known as coronavirus disease 2019 (COVID-19) resulted in the emergence of a worldwide pandemic. Control measures to mitigate the spread of COVID-19 resulted in numerous reports of children missing routine vaccines along with the stopping of many public health immunization programs. Finally, armed conflicts and war have led to large family migrations from their homelands to various countries and regions leading to increased risk for missed maternal and child immunization as well as difficulty in keeping vaccination records. [Pediatr Ann. 2022;51(11):e426-e430.].
Chapter
Beliefs play a central role in our lives. They lie at the heart of what makes us human, they shape the organization and functioning of our minds, they define the boundaries of our culture, and they guide our motivation and behavior. Given their central importance, researchers across a number of disciplines have studied beliefs, leading to results and literatures that do not always interact. The Cognitive Science of Belief aims to integrate these disconnected lines of research to start a broader dialogue on the nature, role, and consequences of beliefs. It tackles timeless questions, as well as applications of beliefs that speak to current social issues. This multidisciplinary approach to beliefs will benefit graduate students and researchers in cognitive science, psychology, philosophy, political science, economics, and religious studies.
Article
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Do cities accelerate COVID-19 transmission? Increased transmission arising from population density prompts spatial policies for financial support and containment, and poorer prospects for recovery. Using daily case counts from over 3,000 counties in the U.S. from February to September 2020, I estimate a compartmental transmission equation. Rational sheltering behavior plausibly varies by location, so I propose two instruments that exploit unanticipated variation in exposure to potential infection. In the first month of local infections, an additional log point of population density raises the expected transmission parameter estimate by around 3%. After the first month, the relation vanishes: density effects occur only in the outbreaks. Public transport, work-from-home jobs and income explain additional variation in transmission but do not account for the density effects. Consistent with location-varying optimal sheltering behavior, I document stronger mobility declines in denser areas, but only after the first month of infections. These results suggest that differences in transmission between cities and other places do not motivate spatial policies for recovery or containment, or poorer prospects after the pandemic.
Preprint
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Background The rapid spread of COVID-19 globally has prompted policymakers to evaluate the capacity of health care infrastructure in their communities. Many hard-hit localities have witnessed a large influx of severe cases that strained existing hospitals. As COVID-19 spreads in India, it is essential to evaluate the country's capacity to treat severe cases. Methods We combined data on public and private sector hospitals in India to produce state level estimates of hospital beds, ICU beds, and mechanical ventilators. Based on the number of public sector hospitals from the 2019 National Health Profile (NHP) of India and the relative proportions of public and private health care facilities from the National Sample Survey (NSS) 75th round (2017-2018), we estimated capacity in each Indian state and union territory (UT). We assumed that 5% of all hospital beds were ICU beds and that 50% of ICU beds were equipped with ventilators. Results We estimated that India has approximately 1.9 million hospital beds, 95,000 ICU beds and 48,000 ventilators. Nationally, resources are concentrated in the private sector (hospital beds: 1,185,242 private vs 713,986 public; ICU beds: 59,262 private vs 35,699 public; ventilators: 29,631 private vs. 17,850 public). Our findings suggest substantial variation in available resources across states and UTs. Conclusion Some projections shave suggested a potential need for approximately 270,000 ICU beds in an optimistic scenario, over 2.8 times the estimated number of total available ICU beds in India. Additional resources will likely be required to accommodate patients with severe COVID-19 infections in India.
Article
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To date, non-pharmacological interventions (NPI) have been the mainstay for controlling the coronavirus disease-2019 (COVID-19) pandemic. While NPIs are effective in preventing health systems overload, these long-term measures are likely to have significant adverse economic consequences. Therefore, many countries are currently considering to lift the NPIs—increasing the likelihood of disease resurgence. In this regard, dynamic NPIs, with intervals of relaxed social distancing, may provide a more suitable alternative. However, the ideal frequency and duration of intermittent NPIs, and the ideal “break” when interventions can be temporarily relaxed, remain uncertain, especially in resource-poor settings. We employed a multivariate prediction model, based on up-to-date transmission and clinical parameters, to simulate outbreak trajectories in 16 countries, from diverse regions and economic categories. In each country, we then modelled the impacts on intensive care unit (ICU) admissions and deaths over an 18-month period for following scenarios: (1) no intervention, (2) consecutive cycles of mitigation measures followed by a relaxation period, and (3) consecutive cycles of suppression measures followed by a relaxation period. We defined these dynamic interventions based on reduction of the mean reproduction number during each cycle, assuming a basic reproduction number (R0) of 2.2 for no intervention, and subsequent effective reproduction numbers (R) of 0.8 and 0.5 for illustrative dynamic mitigation and suppression interventions, respectively. We found that dynamic cycles of 50-day mitigation followed by a 30-day relaxation reduced transmission, however, were unsuccessful in lowering ICU hospitalizations below manageable limits. By contrast, dynamic cycles of 50-day suppression followed by a 30-day relaxation kept the ICU demands below the national capacities. Additionally, we estimated that a significant number of new infections and deaths, especially in resource-poor countries, would be averted if these dynamic suppression measures were kept in place over an 18-month period. This multi-country analysis demonstrates that intermittent reductions of R below 1 through a potential combination of suppression interventions and relaxation can be an effective strategy for COVID-19 pandemic control. Such a “schedule” of social distancing might be particularly relevant to low-income countries, where a single, prolonged suppression intervention is unsustainable. Efficient implementation of dynamic suppression interventions, therefore, confers a pragmatic option to: (1) prevent critical care overload and deaths, (2) gain time to develop preventive and clinical measures, and (3) reduce economic hardship globally.
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BACKGROUND: With its epicenter in Wuhan, China, the COVID-19 outbreak was declared a Public Health Emergency of International Concern by the World Health Organization (WHO). Consequently, many countries have implemented flight restrictions to China. China itself has imposed a lockdown of the population of Wuhan as well as the entire Hubei province. However, whether these two enormous measures have led to significant changes in the spread of COVID-19 cases remains unclear. METHODS: We analyzed the available data on the development of confirmed domestic and international COVID-19 cases before and after lockdown measures. We evaluated the correlation of domestic air traffic to the number of confirmed COVID-19 cases and determined the growth curves of COVID-19 cases within China before and after lockdown as well as after changes in COVID-19 diagnostic criteria. RESULTS: Our findings indicate a significant increase in doubling time from 2 days (95% CI: 1.9-2.6) to 4 days (95% CI: 3.5-4.3), after imposing lockdown. A further increase is detected after changing diagnostic and testing methodology to 19.3 (95% CI: 15.1-26.3), respectively. Moreover, the correlation between domestic air traffic and COVID-19 spread became weaker following lockdown (before lockdown: r = 0.98, P < 0.05 vs after lockdown: r = 0.91, P = NS). CONCLUSIONS: A significantly decreased growth rate and increased doubling time of cases was observed, which is most likely due to Chinese lockdown measures. A more stringent confinement of people in high risk areas seems to have a potential to slow down the spread of COVID-19. © International Society of Travel Medicine 2020. All rights reserved. For Permissions, please e-mail: [email protected]
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What happens next? Four months into the severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) outbreak, we still do not know enough about postrecovery immune protection and environmental and seasonal influences on transmission to predict transmission dynamics accurately. However, we do know that humans are seasonally afflicted by other, less severe coronaviruses. Kissler et al. used existing data to build a deterministic model of multiyear interactions between existing coronaviruses, with a focus on the United States, and used this to project the potential epidemic dynamics and pressures on critical care capacity over the next 5 years. The long-term dynamics of SARS-CoV-2 strongly depends on immune responses and immune cross-reactions between the coronaviruses, as well as the timing of introduction of the new virus into a population. One scenario is that a resurgence in SARS-CoV-2 could occur as far into the future as 2025. Science , this issue p. 860
Article
The public health community needs to learn from history and needs to regain its ability to do shoe-leather public health. If we come together collectively and use the public health tools that we have at hand, we will be successful in containing COVID-19 despite geopolitical tensions, just as we were successful in eradicating smallpox despite the Cold War at the time.
Article
As cases of COVID-19 are being declared the Global South, low- and middle-income countries brace themselves for the pandemic. Low- and middle-income countries brace themselves for the pandemic. World COVID
Article
Drastic public health measures such as social distancing or lockdowns can reduce the loss of human life by keeping the number of infected individuals from exceeding the capacity of the health care system but are often criticized because of the social and the economic cost they entail. We question this view by combining an epidemiological model, calibrated to capture the spread of the COVID-19 virus, with a multisector model, designed to capture key characteristics of the U.S. Input Output Tables. Our two-sector model features a core sector that produces intermediate inputs not easily replaced by inputs from the other sector, subject to minimum-scale requirements. We show that, by affecting workers in this core sector, the high peak of an infection not mitigated by social distancing may cause very large upfront economic costs in terms of output, consumption and investment. Social distancing measures can reduce these costs, especially if skewed towards non-core industries and occupations with tasks that can be performed from home, helping to smooth the surge in infections among workers in the core sector.